Ethical Pain Management: Have the Tides Changed? Helen N Turner, DNP, RN BC, PCNS BC, FAAN Clinical Nurse Specialist, Pediatric Pain Management ASPMN President Elect turnerh@ohsu.edu Conflict of Interest Disclosure Educational Webinar Gannett Education Educational Presentations Purdue Pharma Advisory Panel AcelRx Any views or opinions in this presentation are solely those of the author/presenter and do not necessarily represent the views or opinions of the American Society for Pain Management Nursing. Objectives Attendees will be able to: 1. Outline three ethical conflicts in pain management that may or may not have changed over time. 2. Recognize at least four signs of moral distress 3. Formulate three strategies useful for decreasing moral distress 1
Ethics Defined Systematic way to form value judgments on human actions Is organized and reflective Is NOT intuitive or based on gut feeling Critical concept: We make judgments all the time What results from these judgments? Healthcare Ethics Bioethics Clinical ethics In clinical care settings Ethics of the encounter between clinician and patient Research ethics Organizational ethics Ethics and Pain Management Pain management is a basic human right. Declaration of Montreal, 2010 2
Medical Ethics &Pain Management Both are relatively young fields (< 50 years) Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions. Relieving Pain in America, 2011, IOM Guiding Constructs of Ethics Beneficence Nonmaleficence Autonomy Justice Fidelity Veracity View from 30,000 feet Beneficence Act for the patient s benefit Relieve pain and suffering Keep society safe 3
Nonmaleficence Do no harm Stopping a medication shown to be harmful Refusing to provide a treatment that has not been shown to be effective Increased opioid prescriptions = increased opioids on the street An decision is required To act or not Doing nothing may cause harm Autonomy Individual right to decide Pain may impair autonomy Assumption of incompetence maybe a violation Accepting or rejecting care or components of care Opioids only We do not always agree with patients decision Ritualistic mutilation Justice Equitable Access to care Resource utilization Discrimination Societal impact (abuse, misuse, death related) 4
Fidelity Faithfulness to obligations, duties, observances Loyalty to patient s interests Fidelity by Briton Riviere Veracity Truth telling Trusting Truth by Bernini Conflict Opposition Inherent incompatibility Internal or external 5
Patient centric Conflict Poorly controlled pain Conflict with patient/family Concerns about addiction/misuse Questioning patient s experience/knowledge Determining competence Clinician centric Conflict Balancing beneficence and nonmaleficence Benefits of action Vs risks of action (or inaction!) Interprofessional conflict To prescribe or not Systems barriers Areas of Potential Conflict Pain management agreements Do patient rights supersede societal rights Multidisciplinary treatment Vs Interventional Managing pain Vs measuring disability Conflicting guidelines Direct to patient marketing 6
Ethical Conflict Leads to Moral Distress HOWEVER, Moral Distress Unethical Moral Distress Feelings of frustration, anger, and anxiety when facing institutional obstacles and interpersonal conflicts about ones values Unruh, 2010 7
Impact on Patient Care Safety Quality Living with moral distress does harm!! Recognizing Moral Distress Responses to moral distress Physical Emotional Behavioral Spiritual 8
Physical Cues Fatigue Headaches Impaired sleep Lethargy Nausea Indigestion Heartburn Emotional Cues Anger Fear Guilt Sorrow Anxiety Grief Behavioral Cues Apathy Indifference Avoidance Agitation Hostility 9
Spiritual Cues Loss of meaning Loss of control Crisis of faith Moral distress leads to professional burnout Recognize Moral Distress American Association of Critical Care Nurses: The 4A s to Rise Above Moral Distress. 10
ASK Am I feeling distressed or showing signs of suffering? GOAL: Become aware of moral distress AFFIRM Your distress, your commitment to take care of yourself, and your professional responsibility to act GOAL: Make commitment to deal with your distress ASSESS Identify source of your distress, determine the severity of the situation, and contemplate your readiness to act GOAL: Ready to make an action plan 11
ACT Prepare to act or not, take action, and maintain desired change or accept the outcome GOAL: Preservation of integrity and authenticity From Distress to Courage Taming the Tide Moral Courage The willingness to stand up for and act according to one s ethical beliefs Lachman et al, 2012 Is a virtue Morally courageous professionals persevere to stand up for what is right even if it means they may do so alone. 12
Developing Moral Courage Personal Professional Organizational Links of Courage by Larry Poncho Personal Attributes Awareness of own beliefs and values Take time for reflection Choice Vs Judgment Support Strong skills in effective communication and advocacy Advance your moral reasoning Nurture your personal ethic of care Professional Attributes Debriefing peer support Developing supportive environment Building consensus Promoting interprofessional collaboration Enhancing professional and cultural competence 13
Professional Attributes Follow a professional model of nursing care that exemplifies nursing s goal of enhancing lives of patients & colleagues Positively influence outcomes that support rather than oppose moral decision making Safety Quality Organizational Attributes Administrative support of moral courage Open communication at all levels Policies and procedures supporting ethical practice Staff empowerment and protection Healthy work environment Interdisciplinary engagement Just Culture Review Education Monitoring Intervene Reflect Support Communicate Self care 14
Have the Tides Changed? I believe some have not Conflicts remain I believe some have Time and experience lead to new knowledge and new conflicts Ethical practice has not Doing the right thing How Do We Stay Afloat? Evolving knowledge and experience Recognize moral distress Develop moral courage Understand consequences of judgment Stay the ethical course! Do the right thing!! Thank You!!! 15